Question

While you are editing a speech-recognized draft H&P, you notice that the dictation is organized by body system and refers to subjective information, specifically the presence or absence of symptomatology in that body system. As an HDS, you are aware that this part of the report is called the:

a) Diagnosis section.
b) Assessment section.
c) Body System section.
d) Symptomatology section

Answer 1

The part of the H&P report referring to the subjective presence or absence of symptomatology within a body system is known as the Symptomatology section. Symptoms like nausea and pain are subjective indicators used in diagnosis but are subjected to individual perception and memory.

Step-by-step explanation:

When editing a speech-recognized draft H&P (History and Physical) and you come across a section that is organized by body system, referring to subjective information on the presence or absence of symptomatology within that body system, this part of the report is commonly termed as the Symptomatology section. These symptoms, which include experiences like nausea, loss of appetite, and pain, are internal conditions reported by the patient. Unlike objective signs, these cannot be directly observed or measured by a healthcare provider. Therefore, they play a significant role in the diagnostic process, although they are subject to the patient's personal perception and memory bias.